Provider Demographics
NPI:1376809863
Name:COOPER, KEITH M (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14312 N 31ST PLACE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:408-253-4150
Mailing Address - Fax:408-253-1979
Practice Address - Street 1:11050 N SAGUARO BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-5549
Practice Address - Country:US
Practice Address - Phone:480-837-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397781223P0700X
AZD009480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770434153OtherFED TX ID